Tag Archives: shared decision making

Summer is here. People are going out and eating strange food, getting stung by strange things, and in general, coming into the ED for interesting rashes.

Contrary to a previous post suggesting a longer taper for contact dermatitis, this paper suggests that steroids are well, quite bunk for urticarial rashes.

This French, two-center, randomized, double-blinded study look at 5mg of levocetirizine vs 5mg of levocetirizine plus 4 days of 40mg prednisone for acute urticaria of under 24 hours duration. Patients were excluded if they had angioedema or anaphylaxis – among a multitude of other things, such that only 100 of 710 potentially eligible patients were enrolled (exclusion criteria comprised of: a history of diabetes, peptic ulcer disease, pregnancy, and chronic kidney disease, among many others).

The authors note that in Italy (strangely, why not in France?) , 93% of patients presenting to the ED for urticaria received steroids in 2011 – which I imagine is probably slightly higher than what I would expect for US EDs. So they reasonably suggest that, hey, maybe we can lower steroid-related ADR’s if we find a way to decrease the number of times we prescribe them.

Basically, after 1 hour, 2 days, and 5 days, there was no difference in itch control or rash resolution between the two groups, and if anything, a trend towards better outcomes with levocitirizine alone (For instance, 62% with an itch score of zero for steroids + levocitirizine vs 76% in levocitirizine only at 2 days). Relapse rates were 30% vs 24% (steroids+levo vs levo only) during the first 5 days, which was not statistically significant.

Sadly, and oddly, they report that “one patient in the placebo group had vomiting and abdominal pain in the ED 1 hour after initiation of treatment. These symptoms were related to anaphylaxis, and the patient rapidly improved after a steroid injection.” … which as we know, probably was not anaphylaxis if it improved “rapidly” after steroids (and without adrenaline). But I digress…

Previously, there have only been two studies looking at steroid use for urticaria; This one showing earlier resolution with 3 days of prednisolene (unsure if this is prednisolone, prednisone, or something else) against 10mg of loratadine (94% vs 66% resolution at 3 days), and this one showing lower itch scores with 4 days of 40mg prednisone plus 25mg of hydroxyzine every 4-8 hours than hydroxyzine treatment alone.

I think this particular study lends some credibility to those of us that are steroid-averse, and probably lends to a reasonable discussion with patients that are concerned about getting steroids. Likewise, it is probably reasonable to do a single dose dexamethasone treatement and chase it with a short course of levocitirizine.

There is yet another paper to further elucidate who should get the CT / LP work up for subarachnoids. The authors looked at six EDs over 5 years, and encompassed 2,248 patients – of which 1898 had suitable LPs for analysis (insufficient sample, exposed to light [?], blood contamination, incorrect storage or transport [?], or they just plain lost the sample). CT reads were done by on-call radiologists in training (I imagine that means residents), or by board-certified radiologists. Images were then reviewed by a board-certified neuro-radiologist OR by a board-certified general radiologist for a final report. There was no “time limit” from onset of headache for exclusion (ie, patients did not need to be scanned within six hours).

92 patients of the 1898 patients were positive for blood via spectrophotometry – 4.8%. Nine of these positives ended up having a subarachnoid hemorrhage (9.8% of their LPs, or 0.47% of patients). What do these nine patients generally have in common? Six of them had a headache for a week or longer. One had a previously coiled embolism. One had a negative CT performed within 3 hours of onset. All of these nine patients got coiled or clipped.

So, what do we make of these? If you present within 6 hours with a negative CT (or, dare I say, less than a week!), you have a 0.053% of having a subarachnoid. If you still do the LP in those <6hours from onset (or, <1 week from onset), the baseline risk of a false positive is 10% vs 1.1% chance of true SAH.

Time for some well-informed shared decision making, and perhaps a higher threshold for those that present with a prolonged headache. Further good news to take away from this study- it does not seem as neuro-radiologists need to make the call and that the <6 hour proposal can be safely extended to the community setting at this point.

(First link is to free text of article. Pubmed did not have a working link to the paper at time of post. If the first link does not work, try here)

I have been lucky enough to attend ACEP over the last few years, and even luckier to watch David Newman speak. Specifically, I have attended his “Is One Troponin Enough?” lecture, which was practice changing for me. It also encouraged me to drench both my patient discussions and MDM’s in evidence prior to discharging patients. Among others, Newman is at it again in today’s article, found here.

At 3 institutions over 5 years, from July 1, 2008 to June 30, 2013, encompassing over a million ED visits in total at these three institutions combined, the authors sought to determine the incidence of clinically relevant adverse cardiac events in patients hospitalized for chest pain with two negative troponins, normal vital signs at time of arrival to the ED, and nonischemic EKGs throughout their stay. Clinically relevant events were defined as life-threatening arrythmia, inpatient STEMI, cardiac or respiratory arrest, or death during hospitalization.

Essentially, during the 5 year study period, over one million ED visits, and over 11,000 patients admitted with two negative troponins, only 20 patients had an adverse outcome (0.18%). When you exclude abnormal vitals at presentation, ischemic EKG findings, left bundle branch block or a paced rhythm, only 4 events were seen out of 7266 patients (0.06%), with two being non-cardiac, and two (possibly) being iatrogenic.

Wow.

Let’s process this for a minute. When taking all-comers – not just the low risk observation patient- with two negative troponins (drawn between 60-240 minutes in this study) your risk is quite low at 0.18%, now exclude non-ischemic EKGs, patients with abnormal vitals, a paced rhythm, or a left bundle branch block, and your risk is 0.06% of an adverse outcome – and more likely to be iatrogenic than cardiac!

Now let’s couple the above study with this study, where they examined almost 700,000 private-insurance ED patients in 2011 presenting with chest pain. They followed patients that both did and did not receive additional diagnostic testing (exercise stress test, stress ECHO, myocardial perfusion scintigraphy, or coronary CTA). Essentially, the rate of MI at 7 days and 190 days was low overall (0.11% and 0.33% respectively). Most importantly – patients who did not undergo initial non-invasive testing were no more likely to experience a myocardial infarction than those who did not receive additional testing. Compared to no testing, additional testing was associated with significantly higher odds of cardiac catheterization and revascularization procedures without a concomitant improvement in the odds of experiencing an MI.

So why are we consulting cardiology for observation patients with two negative troponins? Why are we ordering stress testing for inpatient or observation patients? This is yet another example of why it is important to provide well-informed consent for your patient, and a great example of a well-intentioned hospitalization and consultation providing (potentially) more harm than good.

It is high time we cease and desist the scare tactics we employ to patients to strong arm them into either an AMA or admission, rather than providing them a look at the current data before making their decision.

11 non-academic hospitals reviewed 760 consecutive patients who had a brain CT for an acute headache that was followed by an LP 12 hrs from the onset of headache from January 2007 to January 2013. These 11 centers diagnosis roughly 250 subarachnoid bleeds annually. In this study, the patients presented within 6 hours from onset of the headache, and all had a negative CT read by staff radiologists, and were independently reviewed by two neuroradiologists and one stroke neurologist. At these 11 centers, of the 760 patients with a negative CT read by staff radiologists, 52 patients had CSF positive for bilirubin (7%). Of these 52 patients, there was one patient identified to have a non-aneurysmal perimesencephalic SAH on repeat review of the images. This one patient had a benign outcome. There were 8 others who had an aneurysm on CTA, DSA, or MRA (3 of which had been previously coiled). All of them were deemed as having rupture unlikely for various reasons (RBC <100, no bilirubin on spectrophotometry, etc).

So, with a negative CT read at a non-academic center by non-neuro radiologists, at the high end, we have a 1 in 760 miss rate if we *only* miss perimesencephalic bleeds on CT. These types of bleeds account for about 5% of SAH, so, potentially, at the low end, we are looking at a miss rate of 1 in 15,200. Essentially, the lumbar puncture is not a very useful test to diagnose SAH – with a posttest probability of 1.9% in cases with a positive CSF spectrophotometric result (a previous study reported about 8% PPV for xanthochromia)

Unfortunately, it is not mentioned how SAH was diagnosed throughout the study period. It would be nice to know if they were made via CT in the ED, as that would help solidify the author’s suggestion that CT/LP is a dinosaur in the age of shared decision making. Speaking of which…

I’ve had a few colleagues who have said, “show them the needle” as a somewhat subversive way to have patients either sign AMA or a refusal to consent for an LP for a subarachnoid hemorrhage. Few, if any, have actually said, “tell them the evidence.”

What sounds better to you for well informed shared decision making?

A) “You could die from this. You need a spinal tap. If you don’t do it, you could die.”

B) “Ultimately, I think your risk of a bleed is low, but I want you to understand that there is significant consequences to a subarachnoid and over half of those diagnosed may die. With that said, studies show that with a normal CT scan, your risk of having this condition is well below 2%. “Normal” spinal tap results performed 12 hours from the onset of your headache helps to further reduce your risk, but also comes with a significant number of false positives. While an abnormal spinal tap is concerning for a subarachnoid, it is not specific, and you will likely require admission for further testing if your spinal tap is abnormal.”

There has been recent discussion in the #FOAM world in regards to labeling otherwise benign conditions (such as GERD in pediatrics) and the patient & family perception requiring medications for this.
Seth Trueger (@mdaware), at ACEP13, brought to my attention an interesting paper in regards to another common labeling of a benign condition, acute bronchitis.

In 2005, 459 patients were presented with a written scenario describing a typical acute respiratory infection in which they were labeled either to have a “chest cold”, “viral infection” or “acute bronchitis” and also were provided with a treatment plan that excluded antibiotic treatment. There is no changes in satisfaction or dissatisfaction with the diagnostic label however, 26% of patients were dissatisfied with treatment 1 provided with the label “bronchitis”and not provided a prescription for antibiotics compared to 13% for a chest cold and 17% for a viral illness respectively. There was no differences in regards to patient’s satisfaction based on age, sex, or education level.

The authors also note that patient pressure is a significant role in antibiotic overprescribing. They note that 54% pediatricians feel parental pressure to inappropriately prescribe antibiotics. For adults, 77% of the time when providers were questioned about antibiotics, they were prescribed first 29% of the time when providers were not asked.

So, to want to decrease your patient dissatisfaction, might I suggest, in the words of Hoffman & Bukata:

“It seems to be a chest cold. Good thing you caught it early before it turned into bronchitis!”

An October 2013 BMJ study compared patients aged 18-70 without underlying lung disease or immunosuppression, with an acute cough of less than one weeks duration. Cough with “discolored” sputum was a requirement of all patients, and they required at least one other symptom of lower respiratory tract infection (dyspnea, wheezing, chest pain or chest discomfort). Patients were excluded if they had previously used NSAIDs or antibiotics within the last 2 weeks, greater than 7 days of cough, allergies to NSAIDs or Augmentin, or had pneumonia on chest film. The three arms were as follows for ten days:

Patients had follow up at 2-4 days, 11-13 days, and again at 30 days if symptoms were not resolved by the second visit. Patients kept a diary of disease severity, daytime cough, night time cough, limitations of ADLs, and fever. There was essentially no difference in the number of days with cough, regardless of treatment, and 12 % of Augmentin patients having an adverse drug reaction, compared to 3% of placebo and 5% of ibuprofen. The authors point out a previous Cochrane review found antibiotics to have a slight advantage over placebo in controlling cough, but that review came from a total of 275 patients – more than a hundred fewer than this trial. The authors are also quick to point out that COPDers have been shown to benefit from antibiotic treatment with a change in sputum color.

The next time a patient states, “but I’m coughing up green stuff,” you’ll have the evidence in hand to either refute the prescription request, or give a risk benefit discussion about the 400% increased rate of side effects from antibiotics over placebo in this setting (12% vs 3%).